Chapter 9. Surgical Therapies For Morbid Obesity

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Chapter 9. Surgical Therapies for Morbid Obesity
John B. Ammori, MD; Jonathan F. Finks, MD
Indications
Body mass index (BMI) > 40.
BMI between 35 and 40 and presence of such comorbid conditions as severe obstructive sleep apnea, pickwickian syndrome, obesityrelated
cardiomyopathy, degenerative joint disease, diabetes mellitus, hypertension, and hyperlipidemia.
Failed dietary attempts at weight loss.
Contraindications
Absolute
Active substance abuse.
Severe psychiatric disorders.
Pregnancy.
Untreated esophagitis.
Relative
BMI < 35.
Age younger than 18 years.
Age older than 60 years.
Desire to become pregnant within 2 years.
Informed Consent
Expected Benefits
Loss of 50–80% of excess weight.
Improvement of comorbid factors.
Potential Risks
Overall mortality < 1%.
Anastomotic leak (1%).
Anastomotic stricture (5–10%).
Wound complications (infection, hernia) more common with open surgery (15–20%) than with laparoscopic procedure (2–5%).
Systemic complications of major surgery (pneumonia, venous thromboembolism, and cardiovascular events).
Equipment
Operating table capable to accommodate the morbidly obese patient.
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Extralarge sequential compression device (SCD) stockings.
Chapter 9. Surgical Therapies for Morbid Obesity, John B. Ammori, MD; Jonathan F. Finks, MD Page 1 / 11
For laparoscopic surgery, video telescopic equipment with two monitors and extralong instruments (laparoscope, graspers, staplers, ultrasonic
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dissector, suction/irrigator).
For gastric bypass procedure, endtoend anastomosis (EEA) stapler.
Wound complications (infection, hernia) more common with open surgery (15–20%) than with laparoscopic procedure (2–5%).
Systemic complications of major surgery (pneumonia, venous thromboembolism, and cardiovascular events).
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Operating table capable to accommodate the morbidly obese patient.
Extralarge sequential compression device (SCD) stockings.
For laparoscopic surgery, video telescopic equipment with two monitors and extralong instruments (laparoscope, graspers, staplers, ultrasonic
dissector, suction/irrigator).
For gastric bypass procedure, endtoend anastomosis (EEA) stapler.
Patient Preparation
Upper endoscopy if indicated by symptoms (heartburn, regurgitation, dysphagia, epigastric pain, anemia).
Right upper quadrant ultrasound to rule out cholelithiasis if indicated by symptoms.
Cardiovascular evaluation.
Psychiatric evaluation.
Nutritionist evaluation.
Patient Positioning
Open Operation
The patient should be supine with arms abducted and extended.
Laparoscopic Operation
The patient should be supine with arms abducted and extended.
Splitleg position is preferable.
Contact and pressure points should be padded.
The patient must be well secured to the operating table.
Procedure
RouxenY Gastric Bypass: Open and Laparoscopic
Figure 9–1: The typical port placement for a laparoscopic approach.
Following port placement, the abdomen is explored.
The jejunum is divided approximately 30–40 cm from the ligament of Treitz and the alimentary (Roux) limb is tagged with Penrose drain.
Figure 9–2: Creation of a sidetoside stapled enteroenterostomy 100–150 cm from the stapled end of the alimentary limb.
The mesenteric defect is closed with permanent sutures.
The omentum is divided with an ultrasonic dissector.
A Nathanson liver retractor is used to elevate the left lateral segment, exposing the proximal stomach.
The patient is placed into steep reverse Trendelenburg position.
Peritoneal attachments between the diaphragm and the cardia at the angle of His are bluntly divided.
The lesser omentum is incised at the pars flaccida portion and divided up to the proximal lesser curvature with an endoscopic stapler.
A gastrotomy is made in the body of the stomach with an ultrasonic dissector. This will be closed with an endoscopic stapler after anvil
introduction.
The anvil from a 25mm EEA stapler is introduced through the 15mm port site and inserted into the gastrotomy. The anvil tip is brought out
through the proximal stomach, near the lesser curvature, between the first and second lesser curvature vessels.
Figure 9–3: Creation of a lesser curvature—based proximal gastric pouch with serial firings of the endoscopic stapler.
The anvil is placed into the stomach via the gastrotomy and pierced through the proximal gastric wall.
The gastrotomy is then stapled, and a 30mL gastric pouch is created below the anvil.
The alimentary limb is brought into an antecolic, antegastric position.
The stapled end of the alimentary limb is opened with the ultrasonic dissector.
Figure 9–4: The 25mm EEA stapler is introduced through the 15mm port site.
The stapler is inserted into the cut end of the alimentary Roux limb and advanced 5–6 cm.
The stapler is opened with the spike exiting the antimesenteric portion of the bowel and readied to connect with the anvil in the gastric
pouch.
through the proximal stomach, near the lesser curvature, between the first and second lesser curvature vessels.
Figure 9–3: Creation of a lesser curvature—based proximal gastric pouch with serial firings of the endoscopic stapler.
The anvil is placed into the stomach via the gastrotomy and pierced through the proximal gastric wall.
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The gastrotomy is then stapled, and a 30mL gastric pouch is created below the anvil.
The alimentary limb is brought into an antecolic, antegastric position.
The stapled end of the alimentary limb is opened with the ultrasonic dissector.
Figure 9–4: The 25mm EEA stapler is introduced through the 15mm port site.
The stapler is inserted into the cut end of the alimentary Roux limb and advanced 5–6 cm.
The stapler is opened with the spike exiting the antimesenteric portion of the bowel and readied to connect with the anvil in the gastric
pouch.
Figure 9–5: The anvil and stapler are mated, taking care that no extraneous tissue comes between the stomach and bowel. The stapler is then
fired and removed from the abdomen, and the donuts are assessed for integrity.
The end of the alimentary limb is divided with an endoscopic stapler and removed.
Figure 9–6: Final reconstruction results in a 100cm Roux limb for patients with a BMI < 50 or a 150cm Roux limb for patients with a BMI > 50. The
distance between the ligament of Treitz and the jejunojejunostomy will similarly range from 30 cm to 100 cm depending on the BMI of the patient.
Upper endoscopy is then performed to rule out an anastomotic leak and to assess for hemostasis.
A 10mm JacksonPratt drain is placed posterior to the gastrojejunostomy and brought out through the right lateral port site.
The fascia of the 15mm port site is closed with interrupted absorbable sutures.
Figure 9–1
Figure 9–2
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Figure 9–2
Figure 9–3
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Figure 9–3
Figure 9–4
Figure 9–5
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Figure 9–4
Figure 9–5
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Figure 9–5
Figure 9–6
Laparoscopic Adjustable Gastric Band
Figure 9–7: Laparoscopic port placement for gastric band procedure.
A Nathanson liver retractor is used to elevate the left lateral segment of the liver, exposing the proximal stomach.
Attachments between the diaphragm and the cardia at the angle of His are bluntly divided.
The gastroesophageal fat pad is excised with an ultrasonic dissector.
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Figure 9–7: Laparoscopic port placement for gastric band procedure.
A Nathanson liver retractor is used to elevate the left lateral segment of the liver, exposing the proximal stomach.
Attachments between the diaphragm and the cardia at the angle of His are bluntly divided.
The gastroesophageal fat pad is excised with an ultrasonic dissector.
The lesser omentum is divided with an ultrasonic dissector beginning at the pars flaccida portion and extending toward the diaphragm to expose
the right crus.
The peritoneum overlying the right crus is incised at approximately the level of the crural decussation.
A bowel grasper from the right lateral port is passed posterior to the esophagogastric junction, emerging at the angle of His.
The band is inserted into the abdomen through the 15mm port. The band tubing is pulled around the stomach using the retrogastric grasper.
Figure 9–8: The band tubing is fed through the buckle until the flanges are through and the band is locked. The band should rotate easily around
the stomach.
An anterior fundoplication is performed with nonabsorbable suture. Interrupted gastrogastric sutures are placed to cover the band, beginning at
the leftmost portion of the fundus and advancing toward the right. Care must be taken to avoid tension and prevent any part of the fundoplication
from covering the buckle of the band.
The band tubing is brought out through the 15mm port and secured. The liver retractor and remaining ports are then removed and the abdomen
is deflated.
The end of the tubing is removed and the tubing is mated to the access port. The port is anchored to the anterior rectus fascia lateral to the 15mm
port site with four interrupted permanent sutures. The incision is then closed in layers.
Figure 9–7
Figure 9–8
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Figure 9–8
Postoperative Care
An upper gastrointestinal study with watersoluble contrast is obtained on postoperative day 1 for the following reasons:
To rule out obstruction or leak from the gastrojejunostomy following RouxenY gastric bypass (open and laparoscopic).
To rule out perforation or obstruction.
To document pouch size and band position following adjustable gastric band placement.
Early ambulation is encouraged.
Deep venous thromboembolism prophylaxis is provided with sequential compression devices and unfractionated or lowmolecularweight
heparin.
The patient is discharged home on a full liquid diet for 2 weeks. The diet is advanced to pureed and then solid food over the next 4 weeks.
Following RouxenY gastric bypass, patients must remain on lifelong supplementation with a multivitamin, calcium, and vitamin B12. They receive
a proton pump inhibitor (PPI) for 3 months to prevent marginal ulceration and ursodeoxycholic acid for 6 months to reduce the risk of
cholelithiasis.
Potential Complications
Anastomotic leak.
Occurs within 10 days postoperatively.
May be treated either conservatively or surgically.
Stomal stenosis.
Occurs as a late complication, usually within 4–6 weeks of surgery.
Most patients respond to endoscopic dilation.
Refractory cases require operative revision.
Marginal ulceration.
Anastomotic leak.
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Occurs within 10 days postoperatively.
May be treated either conservatively or surgically.
Stomal stenosis.
Occurs as a late complication, usually within 4–6 weeks of surgery.
Most patients respond to endoscopic dilation.
Refractory cases require operative revision.
Marginal ulceration.
Occurs in 5–10% of patients.
Patients have epigastric pain or upper gastrointestinal bleeding, or both.
Perforation is less common but has been reported.
Usually responds to PPI but may require endoscopic or surgical intervention.
Internal hernia.
May occur as an early or late complication in 3–5% of patients.
Patients typically present with acute or chronically intermittent obstructive symptoms.
Treatment is surgical.
Incisional hernia (may occur in up to 15% of open operations).
Acute esophageal obstruction.
Gastric prolapse ("slipped band") and pouch dilation.
Band erosion.
Esophageal dilation or dysmotility.
Port and tubing complications (eg, breakage, migration, infection).
Pearls and Tips
A checklist of important operative steps (eg, closure of the gastrotomy, removal of the spike) should be maintained by the circulating nurse to
avoid missed steps.
Care must be taken to correctly identify alimentary and biliary limbs and to prevent twisting of the mesentery. This should be checked and
rechecked.
The mesenteric defect should be completely closed with permanent suture.
The angle of His must be clearly identified during creation of the proximal pouch to prevent injury to spleen or esophagus.
Passage of the bowel grasper behind the esophagogastric junction should occur without any resistance. If resistance is encountered, withdraw
the grasper and reinsert it 5–10 mm caudad.
Complete excision of the gastroesophageal fat pad is important to reduce the risk of esophageal obstruction and facilitate placement of the
fundoplication sutures.
Avoid placement of the fundoplication over the buckle of the band to minimize the risk of band erosion.
Carefully anchor the port to the anterior fascia lateral to the 15mm port to prevent port migration or rotation.
Late port site infections indicate band erosion until proven otherwise.
References
McGrath V, Needleman BJ, Melvin WS. Evolution of the laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech. 2003;13:221–227. [PubMed:

14561250]
NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med. 1991;115:956–961.
Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding: surgical technique. J Laparoendosc Adv Surg Tech. 2003;13: 257–263. [PubMed:
14561254]
References
McGrath V, Needleman BJ, Melvin WS. Evolution of the laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech. 2003;13:221–227. [PubMed:

Access Provided by:
14561250]
NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel. Ann Intern Med. 1991;115:956–961.
Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding: surgical technique. J Laparoendosc Adv Surg Tech. 2003;13: 257–263. [PubMed:

14561254]

Chapter 9. Surgical Therapies For Morbid Obesity

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Chapter 9. Surgical Therapies For Morbid Obesity

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McGrath V, Needleman BJ, Melvin WS. Evolution of the laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech. 2003;13:221–227. [PubMed:

McGrath V, Needleman BJ, Melvin WS. Evolution of the laparoscopic gastric bypass. J Laparoendosc Adv Surg Tech. 2003;13:221–227. [PubMed:

Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding: surgical technique. J Laparoendosc Adv Surg Tech. 2003;13: 257–263. [PubMed:

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